ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 8/1/26
Ambetter·IL · Neurosurgery, Orthopedics, Cardiothoracic Surgery·Claims & Billing
Effective date
Aug 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter of Illinois is updating IONM (Intraoperative Neurophysiologic Monitoring) coverage requirements for Marketplace plans effective August 1, 2026. Only CMS-recognized payable code 95940 with modifier G0453 is covered; code 95941 is non-covered. Billing must comply with strict criteria including exclusive patient attention, maximum 4 units per 60 minutes, appropriate place of service codes, and exclusion from surgeon/anesthesia billing.
Action Required
By July 31, 2026: Billing team must update billing software to enforce IONM coverage rules for Ambetter of Illinois Marketplace plans. (1) Configure system to accept ONLY CPT 95940 with modifier G0453 for reimbursement; flag CPT 95941 as non-covered and auto-deny. (2) Add validation rules: reject claims with >4 units per 60-minute period, reject claims where total units exceed monitoring time available, reject claims billed by surgeon or anesthesia provider (typically included in global surgical package). (3) Add Place of Service validation to require codes 19, 21, 22, or 24 only. (4) Update claim scrubbing rules and denial templates accordingly. (5) Educate providers and surgical centers that IONM must be billed by qualified monitoring technicians, not surgical team. Claims submitted after 8/1/26 without compliance will be denied.